Healthcare Provider Details

I. General information

NPI: 1619699915
Provider Name (Legal Business Name): MARK ILYAGU MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2022
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 E SUNRISE HWY STE 500
VALLEY STREAM NY
11581-1233
US

IV. Provider business mailing address

221 SEA BREEZE AVE APT PH2B
BROOKLYN NY
11224-3454
US

V. Phone/Fax

Practice location:
  • Phone: 717-716-7107
  • Fax:
Mailing address:
  • Phone: 717-716-7107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MARK ILYAGU
Title or Position: MD
Credential:
Phone: 717-716-7107